Anxiety and Depression

Management for

General Providers

Meaghan Rudolph RN MS PMHCNS-BCStephanie Mahnks RN MSN PMHNP-BC

Massachusetts General Hospital Dept of Psychiatry

Disclosures Nothing to disclose

Prevalence Current estimates indicate that 50% of the

population experience at least one mentaldisorder in their lifetime and that at least 25%have suffered a mental disorder in the past year.

At least 1/3 of office visits in primary care have adirect and explicit psychological component.

Recognition, diagnosis, treatment, and referraldepend overwhelmingly on general practitioners.

Assessment What is the patient telling me?

Their interpretation of symptoms

How this is impacting them

What is the patient NOT telling me?

Appearance, what do they look like usually?

What is different from their usual presentation?

Who and what is with them?

Take in the whole picture: movement, mannerisms, attire, gait

Start your assessment in the waiting room

*Once have some data for mood/thought disorder, be sure these are primary psych, r/o all medical causes

Depression Females > Males

Female lifetime prevalence M.D. 21.3%; dysthymia--8%

Male lifetime prevalence M.D. 12.7%; dysthymia—4.8%

Culture

May express somatic concerns more than sadness/mood

disturbance

Onset mean age of onset 40

50% onset between 20 and 50 years of age.

Risk Factor for Depression

Prior episode

Family history

Lack of social support

Stressful life event

Current substance abuse

Medical comorbidity

Depression? Reactive sadness

Emotional response to event

Few hours/days

Does not interfere with functioning

Grief

Interpersonal loss

Sadness tied to the event, no loss of self-esteem

Medical/Medication induced

Thyroid, menopause, CHF,

Caffeine, benzo, birth control, antihypertensive

Diagnostic Criteria

Depression

Depressed Mood or Loss of interestor pleasure (for two weeks)

Plus 4 or more of these: Weight/appetite change

Change in sleep

Psychomotor agitation/retardation

Fatigue/loss of energy

Feelings of worthlessness or guilt

Cognitive changes/difficulty concentrating

Thought of death/suicide

Depressive Disorders Major Depressive Disorder

Single Episode

Recurrent

Dysthymic Disorder

Milder, chronic disorder

Distinguishing feature duration (2 years)

Seasonal Affective Disorder

Depressive episodes related to seasonalvariation in light.

Depressive symptoms in fall and winter; full

remission in spring and summer

Has occurred for at least two years

SIGECAPS S Sleep—decreased or increased

I Interest—deficit; anhedonia

G Guilt—including worthlessness/hopelessness/regret

E Energy--deficit

C Concentration--deficit

A Appetite—increased or decreased

P Psychomotor activity--agitation/retardation

S Sex—deficit of desire

S Suicide—ideation/planning present

Assessment Mnemonics

To diagnosis depression need: Depressed mood/anhedonia for two weeks

PLUS 4 SIG E CAPSS Symptoms

To diagnose dysthymia Depressed mood/anhedonia for two years

PLUS 2 of *SIG E CAPSS Symptoms

PHQ-9Name: Date:

Over the last two weeks, how often have you been bothered by any of

the following problems?Not at all Several days

More than half the

daysNearly every day

Little interest or pleasure in doing things 0 1 2 3

Feeling down, depressed, or hopeless 0 1 2 3

Trouble falling or staying asleep, or sleeping too much 0 1 2 3

Feeling tired or having little energy 0 1 2 3

Poor appetite or overeating 0 1 2 3

Feeling bad about yourself, or that you are a failure, or that you have let

yourself or your family down0 1 2 3

Trouble concentrating on things, such as reading the newspaper or watching

television0 1 2 3

Moving or speaking so slowly that other people could have noticed? Or the

opposite, being so fidgety or restless that you have been moving around a

lot more than usual.

0 1 2 3

Thoughts that you would be better off dead, or of hurting yourself in some

way0 1 2 3

Total ___ = ___ + ___ + ___ + ___

PHQ-9 score ≥10: Likely major depression

Depression score ranges:

5 to 9: mild

10 to 14: moderate

15 to 19: moderately severe

≥20: severe

Bipolar DO Hallmark:

ELEVATED MOOD described as euphoric: unusuallygood, cheerful or high

EXPANSIVE QUALITY OF MOOD characterized by unceasing and indiscriminate enthusiasm forinterpersonal, sexual, or occupational interactions

Must last at least 1 week (or less ifhospitalization is required)

Uninvolved people may not recognizepathology—those who know the patientrecognize it as abnormal

Mania Assessment

DIGFAST D = Distractibility and easy frustration

I = Irresponsibility and erratic uninhibited behavior

G = Grandiosity

F = Flight of ideas

A = Activity increased with weight loss and increasedlibido

S = Sleep is decreased (but feel rested)

T = Talkativeness (noticed by others)

Substance Use Alcohol

Marijuana

Vaping

Edibles

Ilicits

Stimulants

Impact on presentation, treatment and prognosis

Treatment Modalities Collaborative Care

Psychotherapy

CBT

Interpersonal therapy

Supportive therapy

Group Therapy

Complementary techniques

Relaxation

Meditation

Exercise

Light Therapy

ECT (electroconvulsive therapy)

Psychopharmacologic

Treatment of Depression Medication

Severity of illness

Sustained physiological symptoms

Selective serotonin reuptake inhibitors (SSRIs)

Serotonin/norepinephrine reuptake inhibitors(SNRIs)

Atypical antidepressants

Tricyclic antidepressants (TCAs)

Monamine oxidase inhibitors (MAOIs)

Treatment Efficacy of medication in general is comparable

between classes, but fine tuned to patient profile

Initial selection of medication: Target symptoms identified

Side effects/patient preference

Comorbid illness

Drug/drug interactions

First degree relative response

Cost

Characteristics of Depression

Agitated, irritable, suicidal ideation: SSRI

Apathy, low energy: dopamine, SNRI

Determining Treatment Escitalopram*

Fewer side effects

Less drug drug interactions

Citalopram

Paroxetine

Wt gain, sexual dysfunction

Sertraline

GI toxicity

Treatment with SSRIs Some patients may experience increased energy/activation early after

initiation of treatment

But onset usually delayed 2-4 weeks

If no response after 6-8 weeks

Wait- “failure” of a med is often due to adequate trial

Increase dose

When tapering UP schedule face to face/phone to assess efficacy

Increase if SE tolerable

Max dose

Change SSRI

Cross taper

Treatment may be indefinite

Best augmentation if partial response: psychotherapy

Consider augmenting with another appropriate agent

Serotonin Syndrome After initiation of serotonergic agent (24 hours)

Life theratenting

Neuromuscular hyperactivity (tremor, hyperreflexia)

Hyperthermia

Agitation, altered MS

Treatment

Discontinue agents

Supportive care to normalize VS

Serotonin antagonists

Future: determine treatment without use of serotonergic agents

Frequency, Intensity, and Burden

of Side Effects Ratings (FIBSER)

Managing Side Effects Most Side Effects are Immediate, go away with time

Anorgasmia

Reduce dose

Sildenafil prn

Add bupropion

Weight Gain

Exercise

Diet

Augmenting Treatment Tolerating current SSRI well

Illness severity

Time urgency

Willingness to take other medications

Modality Additional SSRI

Additional Agent

Bupropion

Trazodone

Antipsychotic

Mood Stabilizer

Continuation and

Maintenance Continuation

After resolution of major depressive episode

Preserve and enhance remission

Relapse prevention

Maintenance

After recovery

Prevention of subsequent episodes

Pharmacotherapy 6 months +

Maintain/restore baseline functioning

Eliminate any residual symptoms

Discontinuation Syndrome Abruptly stopping SSRI

Occurs within 1-4 days

Symptoms

Dizziness

Fatigue

Headache

Nausea

Least Risk: Fluoxetine

Intermediate: Citalopram, escitalopram, sertraline

Most: Paroxetine

Management of

Discontinuation Syndrome Taper slowly as per specific drug recs/patient situation

Need to taper (adverse effect, pregnancy)

Severity of symptoms

Length of treatment (longer then 3-5 weeks requires

taper)

Longer ½ life 2-3 weeks

Shorter ½ life (<24 hours) 4 weeks

Assessment of anxiety

disorders Varies with each disorder

In the last few months have you…

Been frequently worried about several things in life?

Is it hard to control or stop worrying?

Any recurrent panic attacks?

Do experiences cause significant trouble at home or work

GAD 7

Over the last 2 weeks, how often have you been bothered by the following problems?

1. Feeling nervous, anxious, or on edge

2. Not being able to stop or control worrying

3. Worrying too much about different things

4. Trouble relaxing

5. Being so restless that it's hard to sit still

6. Becoming easily annoyed or irritable

7. Feeling afraid as if something awful might happen

Add the score for each column Total Score (add your column scores) =

Diagnosis of Anxiety DO Inclusion and exclusion criteria

Duration

Symptoms

Modifiers and alternatives

Includes symptoms that cannot be explained by

another psychiatric disorder

Symptoms cannot be explained by:

medical condition

substance use

Generalized Anxiety Disorder

(GAD) Excessive anxiety and worry that is difficult to control

occurring more days than not for at least six months

Associated with at least three symptoms:

Restlessness, easily fatigued, difficulty concentrating,

irritability, muscle tension, sleep disturbance

r/o substance abuse; r/o medical causes

Panic Disorder Recurrent panic attacks as characterized by at least four of

the follow symptoms:

Palpitations, sweating, trembling, sensation of shortness of

breath, sensation of choking, chest pain, nausea or abdominal

pain, dizziness, chills or heat sensation, paresthesias, fear of

losing control, fear of dying

Derealization vs. depersonalization

At least one panic attack is followed by at least one month of

the following:

Persistent worry about consequences i.e. ongoing panic attacks

Maladaptive changes to avoid panic attacks

Post Traumatic Stress

Disorder (PTSD)Exposure to actual or threatened death, serious injury or sexual violation, either first hand or witnessed. Person must have at least one of the follow intrusion symptoms for at least one month following experience:

Memories, dreams, flashbacks, exposure distress, physiological reactions

In addition, affected persons must experience one of the following avoidance symptoms for at least one month following experience:

Internal reminders, i.e. avoid thoughts or feelings, External reminders, i.e. avoid people or places

In addition, affected persons must experience at least two of the following negative symptoms for at least one month following experience:

Impaired memory, negative self-image, blame, negative emotional state, decreased participation, detachment, inability to experience positive emotions

And two of the following arousal behaviors:

Irritable or aggressive, reckless, hypervigilance, exaggerate startle response, impaired concentration, sleep disturbance

Treatment Modalities SSRIs gold standard

Block serotonin reuptake pump

Desensitizes serotonin receptors, particularly 1A

receptors

Which one?

Fluoxetine MDD, OCD, PMDD, bulimia nervosa, panic d/o, bipolar

depression, treatment resistant depression in combination

with olanzapine, social anxiety d/o, PTSD

has antagonist properties of 5HT2C receptors would

could increase norepinephrine and dopamine

Fluoxetine side effects: increased serotonin can cause diminished

dopamine responsible for emotional flattened, cognitive slowing, apathy

most side effects are immediate and go away with time

notable SE: sexual dysfunction, GI, CNS (insomnia, h/a), sweating, bruising

life threatening: rare seizures, induction of mania, activation of SI

weight gain and sedation are unlikely

dose range once daily: 20- 80 mg for anxiety disorders

Fluoxetine Stopping med: taper rarely necessary as med has long

half-life and will taper itself upon abrupt discontinuation

Notable drug interactions:

Tramadol: increase risk of seizures

Use with caution with TCAS as can increase level

Can cause fatal serotonin syndrome when used with

MAOIs and need to have stopped MAOI For at least two

weeks prior to starting Prozac, conversely do not start

MAOI after stopping Prozac for at least five weeks

NSAIDS may impair efficacy of SSRIs

Sertraline -MDD, panic d/o, PTSD, GAD, OCD, social anxiety d/o

Block serotonin reuptake pump

Desensitizes serotonin receptors, particularly 1A receptors

Also has some ability to block dopamine reuptake pump

Some patients may experience increased energy/activation early after initiation of treatment, however onset usually delayed 2-4 weeks

If no response after 6-8 weeks, may increase dose or may change SSRI

Treatment may be indefinite

Side effects the same

Augmentation therapies: same as above

Also rare sedation an rare weight gain

Dosing 50- 200 mg once daily

Sertraline With PMDD dose may fluctuate throughout the month

based on symptoms

Mild taper to avoid withdrawal effects: dizziness,

nausea, GI symptoms, generally 50 percent dose

reduction for three days, then repeat until discontinued

Drug interactions: same as above

Citalopram MDD, PMDD, OCD, Panic d/o, GAD, PTSD, social anxiety d/o

Block serotonin reuptake pump

Desensitizes serotonin receptors, particularly 1A receptors

Also has mild antagonist actions at H1 histamine receptors

No known activation effect, onset usually within 2-4 weeks

If no response after 6-8 weeks, may increase dose or may change SSRI

Treatment may be indefinite

Side effects similar however sedation more common due to mild antihistamine properties

Augmentation therapies: same as above

Weight gain unusual

Dose range is 20- 40 mg daily

Taper similar to Sertraline and not usually necessary

Drug interactions: same as above

Augmenting treatment trazodone: best response for insomnia

benzodiazepines: panic attacks

gabapentin: ongoing anxiety

Wellbutrin

Case

Selected References